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Specialist, Referral II

Company: AltaMed Health Services Corporation
Location: Montebello
Posted on: May 3, 2021

Job Description:

OverviewThis position is responsible for providing support to the Medical Management and inter-departmental staff and assisting providers and members/patients with the referral process and status questions and as a resource for patients, providers, staff and external customers regarding authorizations and third-party reimbursement policies as well as facilitating processing of most complex issues with patients and third-party payor issues.Responsibilities Maintains up to date knowledge about payor sources such as Fee for Service, Sliding Fee Scale, Managed Care/HMO, CHDP, Healthy Families, Family PACT, as well as cash. Knowledgeable about the regulations regarding these various payor sources. Handles member/patient inquiries regarding TAR status, the authorization process and other issues in a courteous and professional manner. Performs authorization data entry into the managed care system and referral logs; ensuring that all referrals are tracked through to a completed visit and report received from the specialist. Completes Cash Contract with patients, discussing their responsibilities with them, setting realistic, achievable payment schedules and assisting them in compliance. Maintains patient ledger cards and inputs information to computer on a daily basis. Conducts interviews and verifies financial eligibility of patients applying for the sliding fee schedule. Performs trouble-shooting when problems situations arise; taking independent action to resolve complex issues. Makes recommendations regarding changes, improvements or enhancements to appropriate staff. Creates, generates and maintains a variety of statistical reports as requested or on a scheduled basis. Coordinates and assists with patient appointments as needed and notify patient of authorization status. Prepares denial letters for review by Medical Director, Medical Management Nurse Reviewer(s) and/or QRMC Chairperson. Distributes denial letters to appropriate recipients. Provides oversight for: Communication with CCS Coordinator to facilitate CCS authorizations; third party payers and clinical staff processes to ensure appropriate authorization of services; requests from the physicians according to State, Federal and health timeliness Standards Performs additional duties as assigned. MEASUREMENTS OF SUCCESS: I. MEETS PERFORMANCE REQUIREMENTS Effective time management demonstrated by meeting the established turn-around times and all regulatory and health plan requirements. Measurements: 100% of audits completed and documents submitted within the required time line. No more than three CAPS per health plan per audit. Monitors, tracks, and manages productivity standards and metrics and address any lag in advance. Ability to lead teams of 8-10 Referral Specialists. This includes the day to day supervision, monitoring, refinement, and reporting of each employees productivity and meeting their targets. Managing multiple priorities, demonstrated by ease and productivity to transition between multiple tasks. Measurement: Department Performance Measure. Team player, achieved through assisting co-workers with their workload as asked by the Lead or others and be able to have cross-training to fill in when needed. Basic analytics understanding to track, manage and report outcomes of the referral numbers and escalate issues impacting the TAT. Highly effective communication with members, external constituents, and internal stakeholders. II. EXCEEDS PERFORMANCE REQUIREMENTS All items listed under Meets Expectation, and: Problem solving skills demonstrated by identification, recommendation, and implementation of tactics to improve productivity and team work. Taking initiative. Leading by example. No verbal or written warning in the period prior to the Performance Evaluation Qualifications High school diploma required. Medical Assistant Certificate or Medical Billing Certificate preferred. Minimum two years experience working in a medical billing environment (IPA or HMO preferred), with pre-authorizations and reimbursement regulations pertaining to Medi-Cal, CCS and other government programs required. Prior Utilization Management Experience also required. Prior Lead position experience and Bilingual English/Spanish preferred.

Keywords: AltaMed Health Services Corporation, Montebello , Specialist, Referral II, Other , Montebello, California

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